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The Difficult Airway in Office-Based Anesthesia

Written By:
Friedberg, Barry L. M.D.

Date Published:
Wed, 2010-05-26

The skills required to anticipate and manage a difficult airway are very important skills that the anesthesia provider must possess. However, it is axiomatic that the night before surgery, the patient was breathing room air unassisted by any devices. (Note that this discussion excludes the sleep apnea patient who requires a continuous positive airway pressure device.) It is therefore anesthesia providers who may be creating the difficult airway by the choice of agents and style of administering them.

On the surface, this would appear to be a simple, straightforward question, but the evolution of anesthetic agents and newer brain activity monitors have made this question somewhat more challenging. Local anesthesia provides analgesia only in a localized area. General anesthesia, in contradistinction, provides generalized analgesia in addition to generalized hypnosis. A simplified, working equation for general anesthesia may be hypnosis plus analgesia.

To the editor: With reference to the editorial by Pandit and Cook (1), whilst being the occasional source of PTSD, anaesthesia awareness is not lethal. However, anaesthesia over medication, the natural consequence of failing to monitor depth of anaesthesia, is lethal; specifically to the tune of nearly one American patient every day!(2)

By trending real time, frontalis muscle electromyogram (EMG) as a secondary trace, one can create a relevant device. (3) Responding to spikes in EMG activity as if they were heart rate (HR) or blood pressure (BP) changes is key to making BIS a clinically useful tool. Titrating propofol with BIS without instantaneous EMG is akin to driving one's car with only the rear view mirror.

Universal BIS/EMG monitoring could reduce anaesthesia drug usage by 30% (4) - a dramatic financial insult to anesthesia drug makers who, in turn, provide millions of various forms of support dollars to organized anesthesia. BIS monitoring is cost effective and remains the best available technology to deal with the twin problems of over- and under- anaesthesia medication. (5)

Propofol-Ketamine Technique
Happy Drugs for Happy SurgeryIn spite of critics who point to its club drug reputation and its relatively limited history as an operative anesthetic on human patients, Barry Friedberg, MD, is convinced that ketamine - known as Special K on the street - is the safest pain inhibitor for patients to receive during surgery.

How to Administer PK

1. For pre-emptive analgesia, give patient antihypertensive clonidine (Catapres) 0.2 mg and NSAID rofecoxib (Vioxx) 50 mg PO.2. To reduce salivary secretions from ketamine, inject 0.2 mg glycopyrrolate (Robinul) before induction with propofol.3. Obtain baseline EKG, pulse oximetry and BIS values.4. Gradually introduce (no bolus dose) propofol 2-5 minutes prior to the procedure. Two reasons for the gradual administration: to preserve spontaneous ventilation and to provide a stable level of propofol in the brain before the ketamine is injected.5. Once you've observed loss of both lid reflex and verbal response, administer 50 mg ketamine bolus and wait 2-3 minutes before injecting the local analgesic. Without the BIS monitor, administer ketamine after loss of both lid reflex and verbal response. With BIS, wait until a level of 70-75 before giving the ketamine.
"Think of propofol as the martini," says Dr. Friedberg, "and ketamine as the olive."

"Ketamine has a virtually spotless safety record when administered properly by clinicians," says the 53-year-old Corona del Mar, Calif.-based anesthesiologist who pioneered the propofol-ketamine (PK) anesthesia technique for office-based cosmetic surgery. "We can't say the same for opioids. Opioids depress the patient's drive to breathe as well as the laryngeal or life-protecting reflexes. Not surprisingly, respiratory complications are the number-one cause of anesthetic mishaps in the office setting. Ketamine, on the other hand, supports the breathing drive and increases the life-preserving reflexes."

Ketamine has been used clinically, primarily as a veterinary anesthetic, for 38 years, says Dr. Friedberg, who began using the drug in 1992, because he was going to work in an outpatient facility that had recently experienced the ultimate bad outcome. An otherwise healthy 34-year-old woman died during a routine cosmetic breast procedure using IV sedation with opioids.

Ketamine has been popular in the club scene since the 1980s because of its PCP- and LSD-like hallucinogenic effects. Dr. Friedberg advocates its use in most outpatient surgeries, not just for cosmetic procedures. He says the rate of post operative nausea and vomiting with the generally high-PONV risk group of patients with whom he works is a mere 0.5 percent and the outcome has been consistently reproduced by other clinicians using the same combination of ketamine and propofol. Plus, he says, "you can't have PONV after a patient has had a facelift or a tummy tuck."

A little trip down 'memory lane.'
This little piece caused some outrage when it came out.
In light of the recent uproar about Michael Jackson using propofol for sleep and recent reports about propofol becoming a drug of abuse in the anesthesia profession, I felt it was timely to reproduce this piece. -BLF

Cosmetic surgery: Postoperative pain

Written By:
Friedberg BL

Date Published:
Tue, 2010-04-20

A scholarly review of 80 randomized clinical trials looked for evidence of preemptive analgesia before incision was performed under general anesthesia.

With all respect to my learned colleagues, it is patently clear that postoperative pain is simply a function of intra-operative pain.

Side effect free intra-operative pain has been eliminated by using 'hypnosis first, then dissociation, followed by injection or incision' (2) for any surgery that breaches the skin barrier to the outside world of danger.

Injection of local analgesia after general anesthesia has been shown to not be of preemptive value. (3)

With all respect to my learned colleagues, it is patently clear that postoperative pain is simply a function of intra-operative pain.

Side effect free intra-operative pain has been eliminated by using 'hypnosis first, then dissociation, followed by injection or incision' (2) for any surgery that breaches the skin barrier to the outside world of danger.

Injection of local analgesia after general anesthesia has been shown to not be of preemptive value. (3)

BIS® monitoring has been demonstrated to reduce propofol usage in propofol/alfentanil/N2O technique. The current study investigated the effect of the implementation of routine BIS® monitoring on propofol consumption during office-based propofol-ketamine anesthesia.

Propofol-ketamine anesthesia is a room air, spontaneous ventilation (RASV), dissociative intravenous (IV) sedation technique reported to have a near-zero postoperative nausea and vomiting (PONV) rate. Clonidine premedication has been reported to control blood pressure intra- and postoperatively, as well as to reduce the requirements for hypnotic agents. The Bispectral Index® (BIS®) monitor is a reproducible, objective, observer independence, quantitative measurement of the hypnotic state.

As facility managers and anesthesia providers move beyond the rhetoric and search for real answers to eliminating post-operative nausea and vomiting (PONV) and pain, growing numbers have moved to a minimally invasive anesthetic (MIA)™ approach for minimally invasive procedures. Rather than using benzodiazepines, muscle relaxants, inhalational agents and opioids, an MIA™ approach takes advantage of the surgeon’s use of local anesthesia for the analgesia portion of the hypnosis + analgesia = anesthesia equation.

Patients feel no pain, yet they respond to the surgeon's commands. And After that, they don't remember a thing. Welcome to the world of conscious sedation. Here are 10 pearls to fine-tune your regimen.

Regarding Dr. Wheeland's editorial ("Office-based cosmetic surgery: How can it be proven safe?" Cosmetic Surgery Times Jan/Feb), I am inclined to support Dr. Wheeland's conclusion that general anesthesia (GA) should probably be restricted from use in the office-based practice of cosmetic surgery. My concern is with the undefined use of the term 'general anesthesia' — which may have some unforeseen consequences inimical to patient safety in the office-based setting for cosmetic surgery.

There are no emergency facelifts in my practice. Ironically, the office based anesthesiologist, while dealing with a truly elective patient population, is actually held to a higher standard of care than his institutional based counterpart.

The Effect Of A Dissociative Dose Of Ketamine On The Bispectral Index (BIS®) During Propofol Hypnosis

Written By:
Barry L. Friedberg, MD

Date Published:
Mon, 1999-02-01

To compare the effect of a standardized stimulus during propofol-only hypnosis on the bispectral index (BIS) value with the effect of the injection of local anesthesia for surgery during ketamine plus propofol hypnosis (dissociative monitored anesthesia care). To determine whether ketamine increases the level of propofol hypnosis when used in dissociative doses.

Propofol-ketamine technique is a room air, spontaneous ventilation (RASV), intravenous dissociative anesthetic technique which simulates the operating conditions of general anesthesia without the increased equipment requirements or costs. A total of 2059 procedures were performed on 1264 patients by 38 different surgeons. There were no hospital admissions for postoperative nausea and vomiting (PONV) or uncontrolled pain. All patients were pleased with their anesthetic and no hallucinations were reported. Cost:benefit analysis is presented as well as discussion of dissociative anesthesia being exempt from current California law (AB595).

Multiple anesthetic approaches exist for full face laser resurfacing. The propofol- ketamine technique is reviewed as a reasonable alternative to providing adequate anesthesia for full face laser resurfacing in the office environment.

Re: "Emergence from general anaesthesia and evolution of delirium signs in the post-anaesthesia care unit" Card, et al., doi:10.1093/bja/aeu442

Congratulations to Card et. al. on their recent publication. (1) Missing from their report was any tabulation of delirium suffering patients who received intra-operative brain monitoring vs those who did not. Several recent publications strongly suggest brain monitoring could play a useful role in preventing this perplexing problem. (2,3) However, without a real time component like electromyogram (EMG), brain monitoring is of limited utility. (4) The ultimate goal of my non-profit Goldilocks Anesthesia Foundation is to make brain monitoring a standard of care.